Effect of type II diabetes mellitus on outcomes in patients with acute respiratory distress syndrome

Purpose

The acute respiratory distress syndrome (ARDS) is a life-threatening condition, whereas the presence of diabetes has been shown to be protective in its development. We undertook this study to assess the association of type II diabetes mellitus with clinical outcomes in patients with ARDS.

Materials and Methods

We retrospectively examined the medical records of consecutive series of patients with ARDS requiring mechanical ventilation from January 2008 to March 2011. Patients with type I diabetes were excluded from the study. Clinical outcomes such as ventilator-free days, mortality, length of stay in the hospital and intensive care unit (ICU), and reintubations were compared based on the presence of diabetes. Multivariate regression model was used to find if the presence of type II diabetes mellitus predicts ventilator-free days at day 28.

Results

Two hundred forty-nine patients with ARDS were admitted to the ICU during the study period. Fifty (20%) subjects had type II diabetes mellitus. Differences in ventilator-free days, in-hospital mortality, reintubation rate, and length of stay in the hospital or ICU were not statistically significant between diabetic and nondiabetic patients with ARDS. Acute Physiologic and Chronic Health Evaluation II, ICU specialty, use of vasopressors, and the need for reintubation were predictors of ventilator-free days at day 28. The presence of type II diabetes mellitus and its adjustment by body mass index did not show association with ventilator-free days at day 28.

Conclusions

The presence of type II diabetes mellitus is not associated with clinical outcomes in ARDS, even when its presence is adjusted by body mass index.     

适应性支持通气在急性呼吸窘迫综合征中实施保护性通气策略的研究

目的研究适应性支持通气(ASV)在急性呼吸窘迫综合症(ARDS)中实施肺保护通气策略的应用,并探讨其优越性。方法 60例ARDS患者随机分为ASV组和PSIMV组进行机械通气,均实行肺保护通气策略,比较两组患者呼吸力学、血气及血流动力学各指标的变化,以及1 w内镇静剂用量、撤机时间、入住ICU时间、死亡率。结果通气24 h后,ASV组较PSIMV组气道峰压(PIP)、平台压(Pplat)均降低(p<0.05);两组间的血液动力学指标无差异(p>0.05);两组治疗24 h后PaO2、氧合指数、静态肺顺应性均较前改善(p<0.05),ASV组1 w内使用镇静剂用量、撤机时间,住ICU时间均小于PSIMV组(p<0.05),但死亡率无统计学差异。结论对于ARDS患者在实行肺保护通气策略时,ASV和PSIMV通气模式均可改善氧合,死亡率无统计学差异。ASV模式更有效减低PIP、Pplat,能减少镇静剂用量,缩短机械通气时间。适应性支持通气在急性呼吸窘迫综合症中实施肺保护性通气策略具备一定优越性。     

钠尿肽在急性呼吸衰竭性低氧血症病因诊断中的意义

①目的 分析B型钠尿肽(B-type natriuretic peptide BNP)对肺水肿呼吸衰竭性低氧血症病因诊断的临床意义.②方法 回顾分析我院ICU71例患者BNP、心脏超声、胸部X线片、动脉血气分析及CVP等检测资料,根据患者临床特征进行诊断后分为心源性肺水肿呼吸衰竭性低氧血症组(CPE)、非心源性肺水肿呼吸衰竭性低氧血症组(ALI/ARDS),分析BNP的病因诊断中的意义.③结果 CPE组31例BNP均数为(1362±402)pg/mL;ALI/ARDS组40例BNP均数为(315±132)pg/mL;两组比较差异有统计学意义(P＜0.001).④结论 BNP在心源性及非心源性肺水肿性呼吸衰竭低氧血症的病因诊断有较好的价值.     

Therapeutic Effects and Anti-inflammatory Mechanisms of Heparin on Acute Lung Injury in Rabbits

Objectives:  The objectives were to investigate the potential beneficial effects and molecular mechanisms of heparin and low-molecular-weight heparin (LMWH) on acute lung injury (ALI).
Methods:  Forty-eight rabbits were randomized into four groups: normal control group (Group A), lipopolysaccharide (LPS) group (Group B), LPS + heparin group (Group C), and LPS + LMWH group (Group D). The rabbit ALI model was established by intravenous (IV) injection with LPS. Alveolar–arterial O₂ difference (P_A-aO₂), serum tumor necrosis factor α (TNF-α), circulating p38 mitogen-activated protein kinase (p38 MAPK) levels, lung nuclear factor (NF)-κB levels, and lung dry/wet (D/W) ratio were measured, and the lung injury scores were calculated.
Results:  Lipopolysaccharide caused significant increases in P_A-aO₂, serum TNF-α, expression of p38 MAPK in polymorphonuclear neutrophils (PMNs), the lung injury scores, and nuclear factor-κB (NF-κB) activity in the lung tissue and caused a decrease in lung D/W ratio. A positive linear correlation was found between p38 MAPK and TNF-α at 1, 2, 4, and 6 hours ( r  = 0.68, 0.92, 0.93, and 0.93, respectively) and between NF-κB and p38 MAPK and TNF-α at 6 hours (r = 0.94 and 0.83, respectively). IV heparin or LMWH given after LPS treatment attenuated these changes in inflammatory response, oxygenation, p38 MAPK expression, and NF-κB activation.
Conclusions:  The anti-inflammatory mechanisms of heparin in ALI may be inhibiting p38 MAPK and NF-κB activities, and then TNF-α overexpression, thus alleviating the inflammatory reaction.     

ARDS after double extrinsic exposure hypersensitivity pneumonitis

Hypersensitivity pneumonitis or extrinsic allergic alveolitis is a lung disease due to T cell and macrophage activation with IgA, IgG or IgE immunocomplex tissue lesions following extrinsic exposure to organic or inorganic agents. We report a case of hypersensitivity pneumonitis (pigeon protein sensitized) with a second nosocomial exposure to Aspergillus fumigatus proteins from a contaminated oxygen water humidifier: the second extrinsic exposure induced significant acute respiratory failure with ARDS. A pre-existing COPD syndrome requiring prolonged oxygen therapy (7 days) involved lung disease with delayed clinical diagnosis and therapy. Microbiological and mycological analysis of oxygen water humidifiers should be considered, especially for hypersensitivity pneumonitis patients, when a new inexplicable clinical impairment occurs. Received: 17 November 1998 Final revision received: 23 March 1999 Accepted: 30 April 1999     

8例吸入性肺炎患者合并ARDS的救治与护理

急性呼吸窘迫综合征（ARDS）系各种病因引起的肺脏内血管与组织间液体交换功能紊乱，导致肺含水量增加，肺顺应性降低，肺泡萎缩，通气血流比例失调的一种以进行性呼吸困难和顽固性低氧血症为特征的急性呼吸衰竭^[1]。本病起病急骤、发展快、病死率高。常见致病因素有休克、创伤、误吸、肺内或肺外的感染等^[2]。     

What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure?

Purpose  To describe what is defined as normal intra-abdominal pressure (IAP) and how body positioning, body mass index (BMI) and positive end-expiratory pressure (PEEP) affect IAP monitoring. Methods  A review of different databases was made (Pubmed, MEDLINE (January 1966–June 2007) and EMBASE.com (January 1966–June 2007)) using the search terms of “IAP”, “intra-abdominal hypertension” (IAH), “abdominal compartment syndrome” (ACS), “body positioning”, “prone positioning”, “PEEP” and “acute respiratory distress syndrome” (ARDS). Prior to 1966, we selected older articles by looking at the reference lists displayed in the more recent papers. Results  This review focuses on the concept that the abdomen truly behaves as a hydraulic system. The definitions of a normal IAP in the general patient population and morbidly obese patients are reviewed. Subsequently, factors that affect the accuracy of IAP monitoring, i.e., body position (head of bed elevation, lateral decubitus and prone position) and PEEP, are explored. Conclusion  The abdomen behaves as a hydraulic system with a normal IAP of about 5–7 mmHg, and with higher baseline levels in morbidly obese patients of about 9–14 mmHg. Measuring IAP via the bladder in the supine position is still the accepted standard method, but in patients in the semi-recumbent position (head of the bed elevated to 30° and 45°), the IAP on average is 4 and 9 mmHg, respectively, higher. Future research should be focused on developing and validating predictive equations to correct for supine IAP towards the semi-recumbent position. Small increases in IAP in stable patients without IAH, turned prone, have no detrimental effects. The role of prone positioning in the unstable patient with or without IAH still needs to be established.     

颅脑损伤合并呼吸窘迫综合征诊断

颅脑损伤后呼吸窘迫综合征（ARDS）的发病率仅次于肺损伤居第2位 。本病病死率高达35%~85%[2]。针对如何降低病死率,正确的早期诊断及治疗尤为重要。衡水市第四医院神经外科1998至2002年收治该病30例,报告如下。1临床资料1.1一般资料男18例,女12例;年龄18~68岁,平均年龄38岁。致伤原因：交通事故18例,坠落伤6例,头部钝器伤5例,其它1例。损伤类型：广泛性脑挫裂伤10例,颅内血肿5例,     

急性呼吸窘迫综合征早期肺循环细胞学和生化改变的初步研究

给大鼠静脉注射油酸制备实验性急性呼吸窘迫综合征（ＡＲＤＳ）模型。在ＡＲＤＳ发生的早期，用肺动脉导管（ＰＡＣ）从肺小动脉中动态取血，发现肺动脉（ＰＡ）血中白细胞（ＷＢＣ）和血管紧张素Ⅰ转换酶（ＡＣＥ）活性在注射油酸后很快升高，并与肺水肿、血氧分压（ＰａＯ２）有明显相关关系（Ｐ＜０．００１）；ＰＡ血中ＷＢＣ数与股动脉（ＦＡ）血中ＷＢＣ数无明显关系（Ｐ＞０．０５）；而ＰＡ血中ＡＣＥ活性与ＦＡ血中ＡＣＥ活性有明显相关关系（Ｐ＜０．００１）。结果表明，用外周血ＷＢＣ数不能反映肺内的改变；外周血中ＡＣＥ活性的变化可以用于估计肺损伤的情况，因此，对临床ＡＲＤＳ的早期诊断可能有重要的参考价值。